master of science in nursing preceptor · 2008-02-01 · 4 college of nursing and health sciences...

COLLEGE OFNURSING ANDHEALTH SCIENCES CANSECO SCHOOLOF NURSING

TEXAS A&M INTERNATIONAL UNIVERSITY

Master of Science in Nursing PRECEPTOR HANDBOOK

Revised August, 2007

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TABLE OF CONTENTS

Topic Page Number

Introduction 2

Criteria for Selection of Preceptors/ Clinical Agencies 3

Qualified Clinical Preceptor Guidelines 4

Preceptor Agreement 5

General Expectations for Advanced Practice Students 7

Clinical Record 8

Student Clinical Log Instructions 9

Clinical Evaluation Tools 11

Evaluation of Preceptor and Agency 20

Board of Nursing and Advanced Practice Nurses 23

Limited Prescriptive Authority 36

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INTRODUCTION

The purpose of this preceptor handbook is to assist the preceptor in arranging appropriate clinical experiences designed to provide learning opportunities that will meet the clinical objective of each course. It is important that preceptors be clear on the expectations of them and be in agreement regarding the importance of the experience in the preparation of knowledgeable, safe family nurse practitioners.

Included in the handbook are copies of forms required to set up the preceptorships as well as those the students will use to document their clinical activities and those the preceptor, faculty and student will use to evaluate the student as well as the overall experience.

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COLLEGE OF NURSING AND HEALTH SCIENCES CANSECO SCHOOL OF NURSING

TEXAS A&M INTERNATIONAL UNIVERSITY MASTER OF SCIENCE IN NURSING

CRITERIA FOR SELECTION OF AFFILIATE AGENCIES AND CLINICAL PRACTICE SITES

In order to provide a precepted Family Nurse Practitioner (FNP) clinical experience that prepares students to meet the full range of clinical competencies of the FNP, agencies and clinical settings will meet the following criteria:

1. Hold accreditation as appropriate 2. Provide qualified preceptor(s) 3. Provide clients that meet specific course objectives 4. Provide support for progression of student learning experiences 5. Sign affiliation or preceptor agreement 6. Meet approval of course faculty

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QUALIFIED CLINICAL PRECEPTOR GUIDELINES

QUALIFIED PRECEPTOR: An advanced practice nurse, physician or other health care professional acceptable to the Board of Nursing who meets the following requirements:

A. Holds an active, unencumbered* license (where licensure is required), B. Is in current practice in the advanced specialty area, C. Is committed to the concept of the advanced practice nurse, and D. Functions as a supervisor and teacher and evaluates the student’s performance in the

clinical setting. * Unencumbered license – A professional license that does not have stipulations against it.

JOB DESCRIPTION: Clinical preceptors collaborate directly with a faculty member to determine student learning needs, assignments, and to guide, facilitate, supervise and monitor the student in achieving clinical objectives. The clinical preceptor will supervise the student’s performance of skills and other nursing activities to assure safe practice.

FUNCTION AND RESPONSIBILITIES: When clinical preceptorships are used in an advanced education program, the following conditions shall be met: 1. Written agreements between the program, clinical preceptor and the affiliating agency,

when applicable, shall delineate the functions and responsibilities of the parties involved. 2. Criteria for selecting clinical preceptors shall be developed in writing. Competent

clinicians can be considered qualified to be preceptors if they are: A) Authorized to practice as advanced practice nurses in the state in which they practice, or B) A currently licensed health care professional who can provide supervision and teaching in clinical settings appropriate for advanced practice nursing.

3. Written clinical objectives shall be specified and shared with the clinical preceptor prior to the experience.

4. The designated faculty member shall be responsible for the student’s learning experiences and shall communicate regularly with the clinical preceptor and student for the purpose of monitoring and evaluating learning experiences. If site visits are not feasible, communication and evaluation are managed by alternatives such as telephone, written communications, or clinical simulations. Reference: Board of Nursing for the State of Texas, Rule and Regulations § 219.10. Management of Clinical Learning Experiences and Resources. Accessed September 6, 2004 at http://www.bne.state.tx.us/rr219.htm#219.10

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_______________________PRECEPTOR AGREEMENT_____________________ The preceptor agreement permits Texas A&M International Canseco School of Nursing students to participate in a student preceptorship in your facility, ________________. Conditions of this agreement are as follows: a. The affiliation period will be from the following date: _______________to

__________________. b. The student, ___________________, will be under the supervision of

____________________________, acting as the preceptor. c. The Canseco School of Nursing Faculty member, _________________, serves as

the liaison with your facility. _______________________________________________________________________ Preceptor Responsibilities: 1. Participate in a preceptor orientation. 2. Participate in the written agreements between the program, affiliating agency, and

preceptor to specify the responsibility of the program to the agency and the responsibility of the preceptor and agency to the program.

3. Orient the student(s) to the clinical agency. 4. Facilitate the learning needs of the student. 5. Collaborate with faculty to review the progress of the student toward meeting

clinical learning objectives. 6. Provide continuous feedback to the student regarding clinical performance. 7. Contact the faculty if assistance is needed or if any problem with student performance

occurs. 8. Discuss with faculty/student arrangements for appropriate coverage for supervision of the

student should the preceptor be absent. 9. Give feedback to the Nursing faculty regarding the clinical experience with the student

and suggestions for program development.

Nursing Program/Faculty Responsibilities: 1. Responsible and accountable for managing clinical learning experiences of students. 2. Supervise no more than six students in the clinical agencies. 3. Develop criteria for the selection of affiliate agencies or clinical practice settings that

address the need to students to observe and practice safe, effective primary care. 4. Select and evaluate affiliate agencies or clinical practice settings that provide students

with opportunities to achieve the goals of the program. 5. Provide written agreements between the program and the affiliating agencies and specify

the responsibility of the program to the agency and the responsibility of the agency to the program.

6. Develop written agreements jointly with the affiliating agency, review them periodically according to the policies of the program and the affiliating agency, and include provisions for adequate notice of termination.

7. Provide the preceptor an orientation to the philosophy, curriculum, course, and clinical objectives of the nursing program. Discuss student expectations, student’s skills, student guidelines for performance of procedures, and methods of evaluation.

8. Assume overall responsibility for teaching and evaluation of the student. 9. Assure student compliance with standards on immunization, screening, OSHA standards,

CPR, and current liability insurance coverage.

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10. Work cooperatively with the preceptor and the agency to determine student learning needs and appropriate assignments.

11. Meet regularly with the clinical preceptor and the student in order to monitor and evaluate the learning experience.

12. Receive evaluation from the preceptor regarding student performance. 13. Receive evaluation from student regarding whether preceptor and agency met their

learning needs/clinical objectives. 14. Provide recognition to the preceptor for participation as a preceptor, for example, with a

plaque or certificate.

Agency Responsibilities: 1. Maintain ultimate responsibility for the care of clients. 2. Retain responsibility for preceptor’s salary, benefits, and liability. 3. Arrange preceptor’s work schedule so they are available for students. 4. Interpret the preceptor program and expectations of students to other agency personnel

who are not directly involved with the preceptorship.

Student Responsibilities: 1. Maintain open communication with the preceptor and faculty. 2. Maintain accountability for own learning activities. 3. Prepare objectives for each clinical experience as needed. 4. Be accountable for own nursing actions while in the clinical setting. 5. Arrange for preceptor’s supervision when performing procedures. 6. Contact faculty if faculty assistance is necessary. 7. Respect the confidentiality of all information obtained during the clinical experience. 8. Wear appropriate professional attire and university name tags when in the clinical

agency.

Signatures below confirm that the above conditions reflect correctly your understanding of and agreement to this affiliation.

TAMIU Canseco School of Nursing Facility/Preceptor Student:_______________________ Preceptor Name/Title:__________________

Date of approval:________________ Date of approval:______________________

Faculty:_______________________ Agency Name/Title:___________________

Date of approval:________________ Date of approval:______________________

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GENERAL EXPECTATIONS FOR ADVANCED PRACTICE STUDENTS

The following are general expectations for the student in the advanced practice preceptorship. The student will:

1. Use the following steps in diagnostic reasoning and critical thinking skills to identify abnormal findings from the client’s history, physical, and diagnostic tests: Step one: identify the client’s chief complaint; Step two: assess, collect history and physical data in a manner appropriate to the client’s age and presenting complaint; Step three: formulate differential diagnoses, describe and articulate significant pathophysiology related to the client’s chief complaint; Step four: present the findings in a concise, organized, and accurate manner; Step five: order laboratory and diagnostic tests appropriate to the client’s complaint; Step six: select a diagnosis; Step seven: develop a treatment plan, including pharmacologic and non pharmacologic interventions; Step eight: implement and evaluate the plan; Step nine: do a followup on client’s progress.

2. Provide holistic and humanistic primary care to clients/families. 3. Collaborate with the preceptors and other health professionals during the clinical

experience. 4. Notify faculty if there is a change in agencies or preceptors.

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CLINICAL RECORD

FACULTY: ______________________________________________________

STUDENT: ______________________________________________________

PRECEPTOR: ____________________________________________________

Type of Agency

Rural Clinic

Private practice

Public Health

Other

Characteristics of Clients

Gender

Age

Ethnicity

Name & Credential of Preceptor at each agency

Practice Specialty

Certification (if appropriate): Certifying body, #, expiration date

Years of Practice in specialty

Previously precepted APN students? (Y/N)

Licensure (if appropriate): specify #, expiration date

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CLINICAL LOG INSTRUCTIONS

Clinical logs will be submitted to the clinical instructor twice each semester, once at midterm and the other at the last day of classes. See the schedule of classes for the due dates. Logs may be submitted via the Internet. The clinical log the student keeps should provide additional evidence of achievement of course objectives. Each client encounter should be documented. The documentation may be continuous and should be in the following format:

Name: ________________________________________________

Date: _______________________________ # of hours ___________

Cumulative hours: _______________________________

Section One:

Date Age M/F Medical/Nursing Diagnosis

Treatment Plan Comments

Section Two Self evaluation: Do a selfevaluation of your progress toward achieving the course objectives.

TECHNICAL SKILLS Certain technical skills are necessary in a primary care practice. Throughout your clinical experiences you will have the opportunity to observe or perform these skills. Please document in your log when you study/observe or perform the following skills:

Laboratory Assessments a. hematocrit f. saline wet mount b. phlebotomy g. potassium hydroxide (KOH) prep c. urinalysis h. hemoccult slide d. urine microscopy i. cellophane test for pinworms e. selected cultures

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Adjuncts to Physical Examination a. Wood’s light g. electrocardiograms b. fluorescein staining of the eyes h. pulmonary function test c. Schiotz tonometry i. anoscopy d. tympanometry test j. developmental screening e. growth charts k. pap smear f. audiometry l. xrays

Therapeutic Maneuvers a. wound care, including suturing d. incision and drainage b. electrocautery, chemical cautery, and liquid nitrogen application

e. splints, casts

c. cerumen removal

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EVALUATION OF FAMILY NURSE PRACTITIONER (FNP) STUDENT (LEVEL I: USED IN AVANCED HEALTH ASSESSMENT AND WELLNESS/HEALTH PROMOTION)

STUDENT: _______________________________ DATE: _____________________

PRECEPTOR (Print):_______________________ Specialty: ____________________

AGENCY: ___________________________________________________

Please rate the student’s performance using the following scale: Maximum Minimum Unsafe Not Observed

4 3 2 1 0

4 3 2 1 0 Comments (*critical elements)

A. CLINICAL APPROACH 1. Creates an environment of rapport & trust with clients/families in order to help them reach optimal healthcare goals.

*

2. Listens and understands client’s/family’s perception of the problem.

*

3. Uses appropriate style and level of communication.

*

B. CLINICAL ASSESSMENT 4. Performs health histories and physical

examinations in a manner appropriate to the client’s age and presenting complaint.

*

5. Presents the findings in a concise, organized and accurate manner.

*

6. Describes and articulates significant pathophysiology related to the client’s health problem or chief complaint.

*

7. Accurately performs a developmental evaluation and/or mental status examination.

*

8. Identifies and describes patterns of behavior associated with developmental processes, lifestyles, and family relationships.

*

C. ANALYSIS AND DECISION MAKING 9. Establishes a diagnosis by discriminating

between normal and abnormal findings from the history and physical examination.

*

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Preceptor evaluation of FNP p. 2 4 3 2 1 0 Comments (*critical elements)

10. Exercises clinical judgment in differentiating between situations the nurse practitioner can manage and those requiring consultation and/or referral.

11. Suggests appropriate laboratory and diagnostic tests for client’s health problem.

D. CLINICAL MANAGEMENT 12. Provides preventive healthcare and health

promotion instruction for a given group of clients.

*

13. Instructs clients/families about growth & development, life crises, common illnesses, risk factors & accidents appropriately.

*

14. Manages common selflimiting, episodic health problems of clients/families in consultation with preceptor.

15. Manages stabilized chronic illness problems of clients/families in consultation with preceptor.

16. Assists clients to assume greater responsibility for their own health maintenance by providing instruction, counseling, and guidance.

*

17. Uses supportive learning materials as needed (e.g., audiovisuals, pamphlets, brochures, etc.)

*

18. Arranges referrals for clients who need further health evaluation and/or additional services.

19. Documents a health care plan appropriate to the development and functional status of the client.

*

E. EVALUATION 20. Collects systematic data for evaluating the

response of client/family to the health care plan.

*

21. Modifies the plan of care according to the response of the client/family.

22. Demonstrates respect for the uniqueness of clients/families, with culture as an influencing factor.

*

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23. Uses problem solving & critical thinking skills during assessment, diagnosis, & decision making of client’s complaint.

*

Satisfactory clinical performance requires a score of “2” or better on all critical elements (indicated by *) by the end of NURS 5407 FNP I Wellness and Health Promotion.

PRECEPTOR COMMENTS:

1. STRENGTHS OF STUDENT:

2. WEAKNESSES OF STUDENT:

Preceptor (Signature):_______________________________________________

FACULTY COMMENTS:

Faculty (Signature):_________________________________________________

STUDENT COMMENTS:

Student (Signature):_________________________________________________

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EVALUATION OF FAMILY NURSE PRACTITIONER (FNP) STUDENT (LEVEL II: USED IN FNP II and III ACUTE AND CHRONIC ILLNESS I AND II AND DIAGNOSTIC LAB APPLICATIONS)

STUDENT: _______________________________ DATE: _____________________


AGENCY: ___________________________________________________


4 3 2 1 0



*


*


*



*


*


*


*


*



*

15



*


*



*


*


*


*


*


*


*


*



*


*


*

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*

Satisfactory clinical performance requires a score of “2” or better on all critical elements (indicated by *) by the end of NURS 5509 FNP III MANAGEMENT OF ACUTE AND CHRONIC ILLNESS, PART II.

PRECEPTOR COMMENTS:




FACULTY COMMENTS:


STUDENT COMMENTS:


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EVALUATION OF FAMILY NURSE PRACTITIONER (FNP) STUDENT (LEVEL III: USED IN INTEGRATED CLINICAL PRACTICUM)

STUDENT: _______________________________ DATE: _____________________


AGENCY: ___________________________________________________


4 3 2 1 0



*


*


*



*


*


*


*


*



*

18



*


*



*


*


*


*


*


*


*


*



*


*


*

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*

Satisfactory clinical performance requires a score of “2” or better on all critical elements (indicated by *) by the end of NURS 5612 FNP IV Integrated Clinical Practicum.

PRECEPTOR COMMENTS:




FACULTY COMMENTS:


STUDENT COMMENTS:


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EVALUATION OF PRECEPTORS AND AGENCIES

Individual preceptors as well as the agencies in which they practice are evaluated by both faculty and students. In this way, continuous feedback is provided to assure that the most appropriate experiences are being used to promote achievement of program outcomes. Copies of the instruments used for these evaluations are provided on the following pages.

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PRECEPTOR: _________________________ AGENCY: ______________________

EVALUATOR: _________________________ DATE: _________________________

Please rate the preceptor & agency performance using the following scale:

Frequently Sometimes Seldom Not Observed 4 3 2 1 0

PRECEPTOR 4 3 2 1 0 Comments 1. The preceptor’s professional experience was

appropriate. 2. The preceptor was available to the student for clinical

assistance. 3. The preceptor allowed the student to formulate a plan

of care for clients based on the science of nursing and related disciplines.

4. The preceptor allowed the student to use cognitive, affective, perceptual, and psychomotor skills to promote health with clients of diverse cultural backgrounds.

5. The preceptor allowed the student to practice collaborative skills in conjunction with other members of the health care team in order to provide comprehensive care to clients.

6. The preceptor encouraged the student to assume increasing clinical responsibility during the semester.

7. The preceptor communicated clear expectations for student learning.

8. The preceptor provided immediate and adequate feedback with questions and client presentations.

9. The preceptor was supportive and accessible for consultation.

10. The preceptor led student through decision making rather than giving own impressions.

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PRECEPTOR p. 2 4 3 2 1 0 Comments 11. The preceptor allowed student to assess client, make

diagnoses, and suggest interventions and plan care. 12. The preceptor offered constructive comments to

student regarding assessment, diagnosing, planned interventions and care.

13. The preceptor provided an environment for critical thinking and decision making for the student.

AGENCY/CLINICAL SETTING 1. The clinical setting provided opportunities for the

student to meet the clinical objectives. 2. The host personnel fostered and encouraged student

participation on the health team. 3. The agency/facility meeting areas (A/V equipment,

facilities, etc.) were adequate and accessible. 4. The agency/facility had supplies, materials, and

equipment that met student needs. 5. The agency/facility was wellequipped to handle the

client visits. 6. The agency/facility provided the student with good

learning experiences to meet clinical objectives. 7. The agency/facility provided the student with an

environment that stimulated ideas for research. 8. The agency/facility personnel demonstrated an

understanding of professional responsibility through adherence to legal and ethical standards of practice.

COMMENTS: 1. STRENGTHS OF PRECEPTOR:

4. WEAKNESSES OF PRECEPTOR:

3. STRENGTHS OF AGENCY:

4. WEAKNESSES OF AGENCY:

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Board of Nursing

Advanced Practice Nurses §221 §221.1. Definitions. The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise:

(1) Accredited program A program which has been deemed to have met certain standards set by the board or by a national accrediting body recognized by the board.

(2) Advanced educational program A postbasic advanced practice nurse program at the certificate or master's degree level. Beginning January 1, 2003, a master's degree in the advanced practice role and specialty will be required for recognition as an Advanced Practice Nurse.

(3) Advanced practice nurse A registered nurse approved by the board to practice as an advanced practice nurse based on completing an advanced educational program acceptable to the board. The term includes a nurse practitioner, nursemidwife, nurse anesthetist, and a clinical nurse specialist. The advanced practice nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. The advanced practice nurse acts independently and/or in collaboration with other health care professionals in the delivery of health care services.

(4) Authorization to practice The process of reviewing the educational, licensing, certification and other credentials of the registered nurse to determine compliance with the board's requirements for approval as an advanced practice nurse.

(5) Board The Board of Nursing for the State of Texas.

(6) Current certification Initial certification and maintenance of certification by national certifying bodies recognized by the board.

(7) Current practice Maintaining competence as an advanced practice nurse by practicing in the advanced role and specialty in the clinical setting, practicing as an educator in the clinical and/or didactic portion of an advanced educational program of study, or practicing as a consultant or an administrator within the advanced specialty and role.

(8) Graduate advanced practice nurse A registered nurse who has completed an advanced educational program of study and has been granted provisional or interim authorization by the board to practice in the advanced specialty and role.

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(9) Monitored anesthesia care refers to situations where a patient undergoing a diagnostic or therapeutic procedure receive (sic) doses of medication that create a risk of loss of normal protective reflexes or loss of consciousness and the patient remains able to protect the airway for the majority of the procedure. If, for an extended period of time, the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic.

(10) Outpatient setting Any facility, clinic, center, office, or other setting that is not a part of a licensed hospital or a licensed ambulatory surgical center with the exception of all of the following:

(A) clinic located on land recognized as tribal land by the federal government and maintained or operated by a federally recognized Indian tribe or tribal organization as listed under 25 U.S.C. Section 4791 or as listed under a successor federal statute or regulation;

(B) a facility maintained or operated by a state or governmental entity;

(C) a clinic directly maintained or operated by the United States or by any of its departments, officers, or agencies; and

(D) an outpatient setting accredited by either the Joint Commission on Accreditation of Healthcare Organizations relating to ambulatory surgical centers, the American Association for the Accreditation of Ambulatory Surgery Facilities, or the Accreditation Association for Ambulatory Health Care.

(11) Party state Any state that has entered into the Nurse Licensure Compact

(12) Protocols or other written authorization Written authorization to provide medical aspects of patient care which are agreed upon and signed by the advanced practice nurse and the physician, reviewed and signed at least annually, and maintained in the practice setting of the advanced practice nurse. Protocols or other written authorization shall be defined to promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her education and experience. Such protocols or other written authorization need not describe the exact steps that the advanced practice nurse must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs which may be prescribed rather that just list specific drugs.

(13) Shall and must Mandatory requirements

(14) Should A recommendation

(15) Unencumbered A license to practice registered nursing which does not have stipulations against the license.

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§221.2. Authorization and Restrictions to Use of Advanced Practice Titles.

(a) Effective January 1, 2006, a registered nurse holding him or herself out to be an advanced practice nurse shall be authorized to practice and hold a title in the following categories:

(1) nurse anesthetist; (2) nursemidwife; (3) nurse practitioner in the following specialties:

(A) Acute Care Adult; (B) Acute Care Pediatric; (C) Adult; (D) Family; (E) Gerontological; (F) Neonatal; (G) Pediatric; (H) Psychiatric/Mental Health; (I) Women's Health; and/or

(4) clinical nurse specialist in the following specialties: (A) Adult Health/MedicalSurgical Nursing; (B) Community Health Nursing; (C) Critical Care Nursing; (D) Gerontological Nursing; (E) Pediatric Nursing; and (F) Psychiatric/ Mental Health Nursing.

(b) A registered nurse who holds current authorization to practice as an advanced practice nurse issued by the board in any of the categories indicated in the previous subsection shall use that title when functioning in the advanced practice role. A registered nurse who was granted authorization to practice in an advanced role and specialty not indicated in the previous subsection prior to January 1, 2006, may continue to use the advanced practice title approved by the Board provided all requirements for maintenance of advanced practice authorization are met. "Advanced practice nurse" shall not be used as a title.

(c) Unless authorized as an advanced practice nurse by the board as provided for by §§221.4 221.8 of this chapter (relating to Full Authorization, Provisional Authorization; Interim Approval; Petitions for Waiver; and Maintaining Active Authorization as an Advanced Practice Nurse), a registered nurse shall not:

(1) claim to be an advanced practice nurse or hold himself/herself out to be an advanced practice nurse in this state; and/or

(2) use a title or any other designation tending to imply that the person is authorized as an advanced practice nurse.

(d) A registered nurse who violates subsection (c) of this section may be subject to an administrative penalty under §301.501 of the Nursing Practice Act.

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§221.3. Education.

(a) In order to be eligible to apply for authorization as an advanced practice nurse, the registered nurse must have completed a postbasic advanced educational program of study appropriate for practice in an advanced nursing specialty and role recognized by the board. RN to BSN programs shall not be considered postbasic programs for the purpose of this rule.

(b) Individuals prepared in more than one advanced practice role and/or specialty (including blended role or dual specialty programs) shall be considered to have completed separate advanced educational programs of study for each role and/or specialty area.

(c) Applicants for authorization to practice in an advanced role and specialty recognized by the Board must submit verification of completion of all requirements of an advanced educational program that meets the following criteria:

(1) Advanced educational programs in the State of Texas shall be approved by the Board or accredited by a national accrediting body recognized by the board.

(2) Programs in states other than Texas shall be accredited by a national accrediting body recognized by the board or by the appropriate licensing body in that state. A state licensing body's accreditation process must meet or exceed the requirements of accrediting bodies specified in board policy.

(3) Programs of study shall be at least one academic year in length and shall include a formal preceptorship.

(4) Beginning January 1, 2003, the program of study shall be at the master's degree level.

(d) Applicants for authorization as clinical nurse specialists must submit verification of the following requirements in addition to those specified in subsection (*c*) of this section:

(1) completion of a master's degree in the discipline of nursing, and

(2) completion of a minimum of nine (9) semester credit hours or the equivalent in a specific clinical major. Clinical major courses must include didactic content and offer clinical experiences in a specific clinical specialty/ practice area.

(e) Those applicants who completed nurse practitioner or clinical nurse specialist programs on or after January 1, 1998 must demonstrate evidence of completion of the following curricular requirements:

(1) separate courses in pharmacotherapeutics, advanced assessment and pathophysiology and/or psychopathology (psychopathology accepted for advanced practice nurses prepared in the psychiatric/mental health specialty only). These must be graduate level academic courses;

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(2) evidence of theoretical and clinical role preparation;

(3) evidence of clinical major courses in the specialty area; and

(4) evidence of a practicum/ preceptorship/internship to integrate clinical experiences as reflected in essential content and the clinical major courses.

(5) In this subsection, the following terms have the following definitions:

(A) Advanced Assessment Course means a course that offers content supported by related clinical experience such that students gain the knowledge and skills needed to perform comprehensive assessments to acquire data, make diagnoses of health status and formulate effective clinical management plans.

(B) Pharmacotherapeutics means a course that offers content in pharmacokinetics and pharmacodynamics, pharmacology of current/commonly used medications, and the application of drug therapy to the treatment of disease and/or the promotion of health.

(C) Pathophysiology means a course that offers content that provides a comprehensive, systemfocused pathology course that provides students with the knowledge and skills to analyze the relationship between normal physiology and pathological phenomena produced by altered states across the life span.

(D) Role preparation means formal didactic and clinical experiences/ content that prepare nurses to function in an advanced nursing role.

(E) Clinical major courses means courses that include didactic content and offer clinical experiences in a specific clinical specialty/practice area.

(F) Clinical specialty area means specialty area of clinical practice based upon formal didactic preparation and clinical experiences.

(G) Essential content means didactic and clinical content essential for the educational preparation of individuals to function within the scope of advanced nursing practice. The essential content includes but is not limited to: advanced assessment, pharmacotherapeutics, role preparation, nursing specialty practice theory, physiology/ pathology, diagnosis and clinical management of health status, and research.

(H) Practicum/Preceptorship/ Internship means a designated portion of a formal educational program that is offered in a health care setting and affords students the opportunity to integrate theory and role in both the clinical specialty/ practice area and advanced nursing practice through direct patient care /client management. Practicums / Preceptorships/ Internships are planned and monitored by either a designated faculty member or qualified preceptor.

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(f) Those applicants who complete nurse practitioner or clinical nurse specialist programs on or after January 1, 2003 must demonstrate evidence of completion of a minimum of 500 separate, nonduplicated clinical hours for each advanced role and specialty within the advanced educational program.

§221.4. Requirements for Full Authorization to Practice. (a) The registered professional nurse who seeks authorization to practice as an advanced practice nurse must:

(1) hold a current, valid, unencumbered license as a registered nurse in the State of Texas or reside in any party state and hold a current, valid, unencumbered registered nurse license in that state;

(2) submit to the board such evidence as required by the board to insure compliance with § 221.3 of this chapter (relating to Education);

(3) attest, on forms provided by the board to having met the minimum of 400 hours of current practice within the preceding biennium unless the applicant has completed an advanced educational program within the preceding biennium;

(4) attest, on forms provided by the board, to having obtained 20 contact hours of continuing education in the advanced specialty and role recognized by the board every two years. Continuing education in the advanced specialty and role must meet the requirements of chapter 216 of this title (relating to Continuing Education). The 20 contact hours required for RN licensure may be met by the 20 hours required by this subsection; and

(5) submit the required credentialing fee, which is not refundable.

(b) The applicant for advanced practice nurse authorization who completed an advanced educational program on or after January 1, 1996 must submit to the board such evidence as required by the board to ensure the applicant holds current certification in an the advanced nursing role and specialty recognized by the board. Such certification must be granted by a national certifying body recognized by the board. The board reserves the right to designate an available national examination in a closely related specialty which that must be taken in lieu of an examination specifically related to the specialty. If an appropriate certification examination is not available and the board has not designated an alternate examination, the applicant may petition the board for waiver from the certification requirement, according to § 221.7(c) of this chapter (relating to Petitions for Waiver).

(c) Advanced practice nurse applicants who wish to be authorized by the board for more than one designation shall complete additional education in the desired area(s) of approval in compliance with § 221.3 of this chapter and obtain national certification in the advanced role and specialty from a national certifying body recognized by the board. To apply for authorization for more than one designation, the applicant shall submit a separate application and fee for each desired designation.

(d) After review by the board, notification of acceptability of credentials and a certificate verifying approval shall be sent to the advanced practice nurse.

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§221.5. Provisional Authorization. (a) A registered nurse who has completed an advanced educational program as required by §221.3 of this chapter (relating to Education) and registered for a board approved national certification examination following completion of the program may be issued a provisional authorization to practice as a Graduate Advanced Practice Nurse pending notification of the results of the certification examination. An applicant may be eligible for provisional authorization only one time per authorized role. The applicant must apply for provisional authorization within six months of program completion.

(b) The applicant shall request the respective certifying body to notify the board of the applicant's certification examination results.

(c) Provisional authorization to practice as a graduate advanced practice nurse shall expire with the first occurrence of any of the following:

(1) One year from the date of completion of the advanced educational program,

(2) When the applicant receives full authorization to practice as an advanced practice nurse, or

(3) When the applicant receives notice from the national certifying body that he/she has failed the national certification examination.

(d) Failure to pass the certification examination on the first attempt will immediately render the applicant ineligible to practice in the advanced practice role or utilize advanced practice titles. The provisional authorization to practice is rescinded and the application for full authorization to practice is denied.

(1) The applicant must immediately notify the board of the examination results and return the original provisional authorization to practice document to the board's office accompanied by a photocopy of the examination results.

(2) The applicant who fails to pass the certification examination on the first attempt may continue to test until he/she achieves national certification in the advanced role and specialty.

(3) An applicant who fails to pass the certification examination may continue to practice as a registered nurse.

(A) The applicant may not:

(i) Practice as an advanced practice nurse,

(ii) Claim to be an advanced practice nurse or hold himself/herself out to be an advanced practice nurse, or

(iii) Use a title or any other designation tending to imply that the person is authorized as an advanced practice nurse.

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(B) The applicant may utilize his/her advanced knowledge, skills, and abilities if an advanced practice nurse authorized to practice in the same role and an appropriate specialty or a physician in the specialty area:

(i) Agrees to continuously monitor all aspects of the applicant's practice that are beyond the scope of practice of a registered nurse,

(ii) Assumes complete responsibility for all aspects of the care and services provided by the applicant that are beyond the scope of practice of the registered nurse,

(iii) Cosigns all documentation, and

(iv) Continuously remains on site with the applicant and is physically present or immediately available at all times.

(4) When the applicant obtains national certification in the advanced role and specialty, he/she may be eligible to reapply for authorization to practice as an advanced practice nurse. The applicant must meet all requirements for full authorization to practice as an advanced practice nurse as specified in §221.4 of this chapter at the time he/she reapplies.

§221.6. Interim Approval.

(a) Interim approval may be granted by the board pending completion of the application process for a period not to exceed 90 days. Extensions of the interim approval period shall not be granted.

(1) The registered nurse seeking interim approval as an advanced practice nurse must complete documentation provided by the board verifying that he/she meets all requirements of this chapter and has completed and mailed the appropriate documents to the educational program or organization for completion.

(2) A letter shall be issued by the board granting interim approval.

(3) An applicant is eligible for interim approval one time only per specialty and role.

(b) An applicant who submits a request for waiver from the requirements of the rules as set forth in §221.4 (relating to Full Authorization to Practice) and §221.5 (relating to Provisional Authorization) of this chapter shall not be eligible for interim approval.

(c) If an applicant is deemed ineligible for advanced practice authorization, the interim approval will be rescinded immediately, effective on the date the notice is sent by mail. The applicant must cease holding him/herself out as or using titles to imply that he/she is an advanced practice nurse.

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§221.7. Petitions for Waiver and Exemptions

(a) A registered nurse who submits a request for waiver from requirements of the rules must submit documentation as required by the board to support his or her petition and assure the board that he or she possesses the knowledge, skills and abilities appropriate for the role and specialty desired. Those petitioners who are under investigation or current board order are not eligible for waiver.

(b) Petitions for waiver from the program accreditation requirements of §221.3 of this chapter (relating to Education), may be granted by the board for individuals who completed their educational programs on or before December 31, 1996. Petitioners must meet the length of academic program requirements of §221.3 of this chapter and obtain national certification in the advanced role and specialty area.

(c) Petitions for waiver from the current certification requirements of §221.4 of this chapter (relating to Requirements for Full Authorization to Practice) and §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse) may be granted by the board.

(1) Under this section, only those petitioners for which no national certification examination within the advanced role and specialty or a related advanced specialty exists will be considered for waiver by the board.

(2) The board may determine that an available national certification examination in a related specialty and/or role must be taken in lieu of an examination specific to the advanced specialty area.

(d) Waivers from the master's degree requirement will be granted to qualified certificate prepared nursemidwives and women's health care nurse practitioners who complete their programs on or after January 1, 2003 through December 31, 2006. Applicants must meet all other requirements as stated in §221.4 of this chapter.

(1) Those individuals approved on the basis of this waiver shall be limited to providing advanced practice nursing care within the geographical boundaries of the State of Texas. This shall not prevent the individual from utilizing Nurse Licensure Compact privileges to function as a registered nurse.

(2) The applicant must submit all required documentation necessary to demonstrate that the requirements (except for the master's degree) for authorization to practice have been met.

(3) The applicant must submit a written request for waiver of the master's degree requirement.

(4) Interim, provisional or full authorization may be granted to qualified certificate prepared nursemidwives and women's health care nurse practitioners.

(e) Exemptions granting authorization to utilize titles not authorized by §221.2 of this chapter may be granted to qualified applicants who complete their advanced

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educational programs prior to January 1, 2010. Applicants must meet all other requirements as stated in §221.4 of this chapter,

(1) The following specialty titles may be considered for exemption if the individual is not qualified for authorization to utilize a title authorized by §221.2 of this chapter:

(A) Acute Care Clinical Nurse Specialist, (B) Critical Care Nurse Practitioner; (C) Cardiovascular Clinical Nurse Specialist; (D) Emergency Nurse Practitioner or Clinical Nurse Specialist; (E) Family Clinical Nurse Specialist; (F) Home Health Clinical Nurse Specialist; (G) Maternal (Parent)Child Health Clinical Nurse Specialist (with or without subspecialization); (H) Neonatal Clinical Nurse Specialist; (I) Oncology Nurse Practitioner or Clinical Nurse Specialist; (J) Pediatric Critical Care Nurse Practitioner; (K) Perinatal Nurse Practitioner or Clinical Nurse Specialist; (L) School Nurse Practitioner; and (M) Women's Health Clinical Nurse Specialist.

(2) Those individuals authorized on the basis of this exemption shall be limited to providing advanced practice nursing care within the geographical boundaries of the State of Texas. This shall not prevent the individual from utilizing Nurse Licensure Compact privileges to function as a registered nurse. (3) The applicant must submit all required documentation necessary to demonstrate that all requirements for authorization to practice have been met. (4) The applicant must submit a written request for exemption to §221.2 of this chapter and indicate the desired title (5) Interim, provisional, or full authorization may be granted to qualified applicants. (6) Advanced practice nurses authorized to practice on the basis of this exemption shall use the advanced practice title specified on the authorization to practice document provided by the board.

§221.8. Maintaining Active Authorization as an Advanced Practice Nurse.

(a) In conjunction with RN license renewal, the advanced practice nurse seeking to maintain active advanced practice authorization(s) shall:

(1) attest on forms provided by the board to maintaining current national certification by the appropriate certifying body recognized by the board. This requirement shall apply to advanced practice nurses who:

(A) completed an advanced educational program on or after January 1, 1996, or

(B) were authorized as advanced practice nurses based upon obtaining national certification.

(2) attest, on forms provided by the board, to having a minimum of 400 hours of current practice within the preceding biennium;

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(3) attest, on forms provided by the board, to having obtained 20 contact hours of continuing education in the advanced specialty area and role within the preceding biennium. Continuing education in the advanced practice specialty and role must meet requirements of Chapter 216 of this title (relating to Continuing Education). The 20 contact hours required for RN licensure may be met by the 20 hours required by this subsection; and

(4) submit the required fee, which is not refundable.

(b) Failure to renew the registered nurse license or to provide the required fee and documentation for maintaining authorization shall result in expiration of the board's authorization as an advanced practice nurse and limited prescriptive authority where applicable. The individual whose advanced practice authorization has expired may not practice as or use titles to imply that he/she is an advanced practice nurse.

§221.9. Inactive Status.

(a) The advanced practice nurse may choose to change advanced practice nurse status to inactive by providing a written request for such change.

(b) Inactive advanced practice status means that the registered professional nurse may not practice in the advanced practice specialty and role and may not hold himself/ herself out to be an advanced practice nurse by using titles which imply that he/she is an advanced practice nurse. The inactive advanced practice nurse may not utilize his/her limited prescriptive authority.

§221.10. Reinstatement or Reactivation of Advanced Practice Nurse Status.

(a) To reinstate an authorization which has expired due to nonpayment of renewal fees for registered nurse licensure and/or advanced practice authorization, the advanced practice nurse shall meet the requirements as stated in §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse) and pay all required fees.

(b) If less than four years but more than two years have lapsed since completion of the advanced educational program and/or the applicant does not have 400 hours of current practice in the advanced role and specialty during the previous biennium, the advanced practice nurse shall meet the requirements as stated in §221.8 of this chapter and pay all required fees. The applicant shall be required to demonstrate proof of completion of 400 hours of current practice as well as the continuing education requirement as outlined in Chapter 216 of this title (relating to Continuing Education). The 400 hours of current practice shall be obtained under the direct supervision of an advanced practice nurse authorized by the board in the same role and specialty or by a physician the same specialty.

(c) If more than four years have lapsed since completion of the advanced practice educational program and/or the applicant has not practiced in the advanced role during the previous four years, the applicant shall apply for reactivation and meet current

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requirements for maintaining authorization to practice under §221.8 of this chapter and shall:

(1) hold a current, valid, unencumbered license as a registered nurse in the State of Texas or reside in any party state and hold a current, valid, unencumbered registered nurse license in that state; and

(2) successfully complete a refresher course or extensive orientation in the appropriate advanced practice specialty and role which includes a supervised clinical component by a qualified instructor/sponsor.

(A) The course(s)/ orientation shall be of sufficient length to satisfy the learning needs of the inactive advanced practice nurse and to assure that he/she meets the minimum standard for safe, competent care. The course(s)/ orientation shall cover the entire scope of the authorized advanced specialty area. Content shall include, but not be limited to that which is specified in board guidelines.

(B) The instructor/sponsor must provide written verification of satisfactory completion of the course/orientation on forms provided by the board and assurance that the individual has reviewed current practicerelated information pertinent to his/her advanced specialty and role.

§221.11. Identification.

When providing advanced practice nursing care to patients, the advanced practice nurse shall wear clear identification which indicates the individual is a registered nurse with the appropriate advanced practice designation authorized by the board.

§221.12. Scope of Practice.

The advanced practice nurse provides a broad range of health services, the scope of which shall be based upon educational preparation, continued advanced practice experience and the accepted scope of professional practice of the particular specialty area. Advanced practice nurses practice in a variety of settings and, according to their practice specialty and role, they provide a broad range of health care services to a variety of patient populations.

(1) The scope of practice of particular specialty areas shall be defined by national professional specialty organizations or advanced practice nursing organizations recognized by the Board. The advanced practice nurse may perform only those functions which are within that scope of practice and which are consistent with the Nursing Practice Act, Board rules, and other laws and regulations of the State of Texas.

(2) The advanced practice nurse's scope of practice shall be in addition to the scope of practice permitted a registered nurse and does not prohibit the advanced practice nurse from practicing in those areas deemed to be within the scope of practice of a registered nurse.

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§221.13. Core Standards for Advanced Practice.

(a) The advanced practice nurse shall know and conform to the Texas Nursing Practice Act; current board rules, regulations, and standards of professional nursing; and all federal, state, and local laws, rules, and regulations affecting the advanced role and specialty area. When collaborating with other health care providers, the advanced practice nurse shall be accountable for knowledge of the statutes and rules relating to advanced practice nursing and function within the boundaries of the appropriate advanced practice category.

(b) The advanced practice nurse shall practice within the advanced specialty and role appropriate to his/her advanced educational preparation.

(c) The advanced practice nurse acts independently and/or in collaboration with the health team in the observation, assessment, diagnosis, intervention, evaluation, rehabilitation, care and counsel, and health teachings of persons who are ill, injured or infirm or experiencing changes in normal health processes; and in the promotion and maintenance of health or prevention of illness.

(d) When providing medical aspects of care, advanced practice nurses shall utilize mechanisms which provide authority for that care. These mechanisms may include, but are not limited to, Protocols or other written authorization. This shall not be construed as requiring authority for nursing aspects of care.

(1) Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her education and experience. The degree of detail within protocols/policies/practice guidelines/clinical practice privileges may vary in relation to the complexity of the situations covered by such Protocols, the advanced specialty area of practice, the advanced educational preparation of the individual, and the experience level of the individual advanced practice nurse.

(2) Protocols or other written authorization:

(A) should be jointly developed by the advanced practice nurse and the appropriate physician(s),

(B) shall be signed by both the advanced practice nurse and the physician(s),

(C) shall be reviewed and resigned at least annually,

(D) shall be maintained in the practice setting of the advanced practice nurse, and

(E) shall be made available as necessary to verify authority to provide medical aspects of care.

(e) The advanced practice nurse shall retain professional accountability for advanced practice nursing care.

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§221.17 Enforcement.

(a) The board may conduct an audit to determine compliance with §221.4 of this chapter (relating to Requirements for Full Authorization to Practice), §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse), and §221.16 of this chapter (relating to Provision of Anesthesia Services by Nurse Anesthetists in Outpatient Settings).

(b) Any nurse who violates the rules set forth in this chapter shall be subject to disciplinary action and/or termination of the authorization by the board under Texas Occupations Code, §301.452.

Advanced Practice Nurses with Prescriptive Authority §222 §222.1. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

(1) Advanced practice nurse A registered nurse approved by the board to practice as an advanced practice nurse based on completing an advanced educational program acceptable to the board. The term includes a nurse practitioner, nursemidwife, nurse anesthetist, and a clinical nurse specialist. The advanced practice nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. The advanced practice nurse acts independently and/or in collaboration with other health care professionals in the delivery of health care services.

(2) Alternate site A practice site:

(A) Where services similar to the services provided at the delegating physician's primary practice site are provided; and

(B) Located within 60 miles of the delegating physician's primary practice site.

(3) Board The Board of *Nursing* for the State of Texas

(4) Carrying out or signing a prescription drug order Completing a prescription drug order presigned by the delegating physician or signing (writing) a prescription by an advanced practice nurse after that person has been designated to the Board of Medicine by the delegating physician as a person delegated to sign a prescription.

(5) Controlled substance A substance, including a drug, an adulterant, and a dilutant, listed in Schedules I through V or Penalty Groups 1, 1A, or 2 through 4 of chapter 481 Texas Health and Safety Code (Texas Controlled Substances Act). The term includes the aggregate weight of any mixture, solution, or other substance containing a controlled substance.

(6) Dangerous drug A device or a drug that is unsafe for self medication and that is not included in schedules IV or penalty groups IIV of chapter 481 Texas Health and Safety

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Code (Texas Controlled Substances Act). The term includes a device or a drug that bears or is required to bear the legend: "Caution: federal law prohibits dispensing without prescription" or "RX only" or another legend that complies with federal law.

(7) Diagnosis and management course A course offering both didactic and clinical content in clinical decisionmaking and aspects of medical diagnosis and medical management of diseases and conditions. Supervised clinical practice must include the opportunity to provide pharmacological and nonpharmacological management of diseases and problems considered within the scope of practice of the advanced practice nurse's specialty and role.

(8) Eligible sites Sites serving medically underserved populations; a physician's primary practice site; an alternate site; or a facilitybased practice site.

(9) Facilitybased practice site A licensed hospital or licensed long term care facility that serves as the practice location for the advanced practice nurse.

(10) Health Manpower Shortage Area An urban or rural area, population group, or public or nonprofit private medical facility or other facility that the Secretary of the United States Department of Health and Human Services (USDHHS) designates as having a health manpower shortage, as described by 42 USC Section 254e(a)(1) or a successor federal statute or regulation.

(11) Medically Underserved Area (MUA)

(A) An urban or rural area or population group that the Secretary of the United States Department of Health and Human Services (USDHHS) designates as having a shortage of those services as described by 42 USC Section 300e1(7) or a successor federal statute or regulation; or

(B) an area defined as medically underserved by rules adopted by the Texas Board of Health (Texas Department of Health) based on demographics specific to this State, geographic factors that affect access to health care, and environmental health factors.

(12) Pharmacotherapeutics course A course that offers content in pharmacokinetics and pharmacodynamics, pharmacology of current/commonly used medications, and the application of drug therapy to the treatment of disease and/or the promotion of health.

(13) Physician's primary practice site

(A) the practice location at which the physician spends the majority of the physician's time;

(B) a licensed hospital, a licensed longterm care facility, or a licensed adult care center where both the physician and the APN are authorized to practice;

(C) a clinic operated by or for the benefit of a public school district to provide care to the students of that district and the siblings of those students, if consent to treatment at that clinic is obtained in a manner that complies with Chapter 32, Family Code;

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(D) the residence of an established patient; or

(E) another location at which the physician is physically present with the advanced practice nurse.

(14) Protocols or other written authorization Written authorization to provide medical aspects of patient care that are agreed upon and signed by the APN and the physician, reviewed and signed at least annually, and maintained in the practice setting of the APN. Protocols or other written authorization shall be defined to promote the exercise of professional judgment by the APN commensurate with his/her education and experience. Such protocols or other written authorization need not describe the exact steps that the APN must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs that may be prescribed rather than just list specific drugs.

(15) Shall and must Mandatory requirements.

(16) Should A recommendation

(17) Site serving a medically underserved population

(A) a site located in a medically underserved area;

(B) a site located in a health manpower shortage area;

(C) a clinic designated as a rural health clinic under 42 USC 1395x(aa);

(D) a public health clinic or a family planning clinic under contract with the Texas Department of Human Services or the Texas Department of Health;

(E) a site located in an area in which the Texas Department of Health determines there is an insufficient number of physicians providing services to eligible clients of federal, state, or locally funded health care programs; or

(F) a site that the Texas Department of Health determines serves a disproportionate number of clients eligible to participate in federal, state, or locally funded health care programs

§222.2. Approval for Prescriptive Authority.

(a) Credentials: To be approved by the board to carry out or sign prescription drug orders and issued a prescription authorization number, a Registered Nurse (RN) shall:

(1) have full or provisional authorization by the board to practice as an advanced practice nurse.

(A) RNs with provisional authorization to practice as graduate advanced practice nurses who are eligible for prescription authorization numbers shall be limited to prescribing for categories of dangerous drugs only.

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(B) RNs with Interim Authorization to practice as advanced practice nurses are not eligible for a prescription authorization number;

(2) file a complete application for Prescriptive Authority and submit such evidence as required by the board to verify the following educational qualifications:

(A) To be eligible for Prescriptive Authority, advanced practice nurses must have successfully completed courses in pharmacotherapeutics, pathophysiology, advanced assessment, and diagnosis and management of problems within the clinical specialty.

(i) Nurse Practitioners, NurseMidwives and Nurse Anesthetists will be considered to have met the course requirements of this section on the basis of courses completed in the advanced educational program.

(ii) Clinical Nurse Specialists shall submit documentation of successful completion of separate courses in the content areas described in subsection (A) of this section. These courses shall be academic courses from a regionally accredited institution with a minimum of 45 clock hours per course.

(iii) The board, by policy, may determine that certain specialties of Clinical Nurse Specialists meet one or more of the course requirements on the basis of the advanced educational program.

(B) Clinical Nurse Specialists who have been approved by the board as advanced practice nurses by petition on the basis of completion of a non nursing master's degree shall not be eligible for prescriptive authority.

(b) Sites: Prescribing privileges are limited to eligible sites to include sites serving certain medically underserved populations, physician's primary practice sites, alternate sites, and facilitybased practice sites.

(c) Exceptions Granted by the Texas Medical Board: Requirements for utilizing limited prescriptive authority may be modified or waived if a delegating physician has received a modification or waiver from the Texas Medical Board of any site or supervision requirements for a physician to delegate the carrying out or signing of prescription drug orders to the advanced practice nurse.

§222.3. Renewal of Prescriptive Authority.

(a) The advanced practice nurse shall renew the privilege to carry out or sign prescription drug orders in conjunction with the RN license renewal application.

(b) The advanced practice nurse seeking to maintain prescriptive authority shall attest, on forms provided by the board, to completing at least five contact hours of continuing education in pharmacotherapeutics within the preceding biennium.

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(c) The continuing education requirement in subsection (b) of this section, shall be in addition to continuing education required under Chapter 216 of this title (relating to Continuing Education).

§222.4. Minimum Standards for Carrying Out or Signing Prescriptions.

(a) The advanced practice nurse with a valid prescription authorization number:

(1) shall carry out or sign prescription drug orders for only those drugs that are:

(A) authorized by Protocols or other written authorization for medical aspects of patient care; and

(B) prescribed for patient populations within the accepted scope of professional practice for the advanced practice nurse's specialty area; and

(2) shall comply with the requirements for adequate physician supervision published in the rules of the Texas Medical Board relating to Delegation of the Carrying Out or Signing of Prescription Drug Orders to Physician Assistants and Advanced Practice Nurses as well as other applicable laws,

(b) Protocols or other written authorization shall be defined in a manner that promotes the exercise of professional judgement by the advanced practice nurse commensurate with the education and experience of that person.

(1) A protocol or other written authorization:

(A) is not required to describe the exact steps that the advanced practice nurse must take with respect to each specific condition, disease, or symptom; and

(B) may state types or categories of medications that may be prescribed or contain the types or categories of medications that may not be prescribed.

(2) Protocols or other written authorization:

(A) shall be written, agreed upon and signed by the advanced practice nurse and the physician

(B) reviewed and signed at least annually; and

(C) maintained in the practice setting of the advanced practice nurse.

(c) Prescription Information: The format and essential elements of the prescription shall comply with the requirements of the Texas Board of Pharmacy. The following information must be provided on each prescription:

(1) the patient's name and address;

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(2) the name, strength, and quantity of the drug to be dispensed;

(3) directions to the patient regarding taking of the drug and the dosage;

(4) the intended use of the drug, if appropriate;

(5) the name, address, telephone number, and, if the prescription is for a controlled substance, the DEA number of the delegating physician;

(6) address and telephone number of the site at which the prescription drug order was carried out or signed;

(7) the date of issuance;

(8) the number of refills permitted; and

(9) the name, prescription authorization number, original signature, and, if the prescription is for a controlled substance, the DEA number of the advanced practice nurse signing or cosigning the prescription drug order.

(d) Generic Substitution. The advanced practice nurse shall authorize or prevent generic substitution on a prescription in compliance with the current rules of the Texas State Board of Pharmacy relating to Generic Substitution. (03/2002)

§222.5. Prescriptions for Dangerous Drugs.

Advanced practice nurses with full or provisional authorization to practice and valid prescription authorization numbers are eligible to carry out or sign prescription drugs orders for dangerous drugs in accordance with the standards and requirements set forth in this chapter

§222.6. Prescriptions for Controlled Substances.

(a) Advanced practice nurses with full authorization to practice and valid prescription authorization numbers are eligible to prescribe certain categories of controlled substances. Graduate advanced practice nurses who hold provisional authorization to practice shall not authorize or issue prescriptions for controlled substances until they have been issued full authorization to practice by the board.

(b) Advanced practice nurses with full authorization to practice and valid prescription authorization numbers who authorize or issue prescriptions for controlled substances shall:

(1) Limit prescriptions for controlled substances to those listed in Schedules III, IV, or V as established by the commissioner of public health under Chapter 481, Health and Safety Code (Texas Controlled Substances Act);

(2) Issue prescriptions for a period not to exceed 30 days;

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(3) Not authorize the refill of a prescription for a controlled substance prior to consultation with the delegating physician and notation of the consultation in the patient's chart; and

(4) Not authorize the prescription of a controlled substance for a child less than two years of age prior to consultation with the delegating physician and notation of the consultation in the patient's chart.

(c) All other standards and requirements as set forth in this chapter relating to carrying out or signing prescription drug orders by advanced practice nurses must be met. In addition, advanced practice nurses with full authorization to practice and valid prescription authorization numbers must comply with all federal, state and local laws and regulations relating to the prescribing of controlled substances, including but not limited to, requirements set forth by the Texas Department of Public Safety and the Drug Enforcement Administration.

§222.7 Prescribing at Sites Serving Certain Medically Underserved Populations.

When carrying out or signing prescription drug orders at a site serving a medically underserved population, the advanced practice nurse shall:

(1) maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice nurse and the delegating physician at least annually;

(2) have access to the delegating physician or alternate delegating physician for consultation, assistance with medical emergencies, or patient referral;

(3) provide a daily status report to the physician on any problems or complications encountered that are not covered by protocol; and

(4) shall be available during onsite visits by the physician which shall occur at least once every 10 business days that the advanced practice nurse is on site providing care.

§222.8. Prescribing at Physicians' Primary Practice Sites.

When carrying out or signing prescription drug orders at a physician's primary practice site, the advanced practice nurse shall:


(2) sign or cosign prescription drug orders only for those patients with whom the physician has established or will establish a physicianpatient relationship although the physician is not required to see the patient within a specified time period.

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§222.9. Prescribing at Alternate Sites.

When carrying out or signing prescription drug orders at an alternate site, the advanced practice nurse shall:


(2) be onsite with the physician at least twenty percent of the time; and

(3) have access to the physician through direct telecommunication for consultation, patient referral, or assistance with a medical emergency;

§222.10. Prescribing at Facilitybased Practice Sites.

When carrying out or signing prescription drug orders at a facilitybased practice site, the advanced practice nurse shall:

(1) maintain Protocols or other written authorization developed in accordance with facility medical staff policies and reviewing the authorizing documents with the appropriate medical staff at least annually;

(2) sign or cosign prescription drug orders in the facility in which the delegating physician is the medical director, the chief of medical staff, the chair of the credentialing committee, or a department chair; or a physician who consents to the request of the medical director or chief of the medical staff to delegate; and

(3) sign or cosign prescription drug orders for the care or treatment of only those patients for whom physicians have given their prior consent.

§222.11. Conditions for Obtaining and Distributing Drug Samples.

The advanced practice nurse with a valid prescription authorization number may request, receive, possess and distribute prescription drug samples provided:

(1) all requirements for the advanced practice nurse to sign prescription drug orders are met;

(2) Protocols or other physician orders authorize the advanced practice nurse to sign the prescription drug orders;

(3) the samples are for only those drugs that the advanced practice nurse is eligible to prescribe in accordance with the standards and requirements set forth in this chapter; and

(4) a record of the sample is maintained and samples are labeled as specified in the Dangerous Drug Act (Health and Safety Code, Chapter 483) or the Controlled Substances Act (Health and Safety Code, Chapter 481) and 37 Tex. Admin. Code chapter 13.

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§222.12. Enforcement.

(a) Any nurse who violates these rules shall be subject to removal of the authority to prescribe under this rule and disciplinary action by the board under Texas Occupations Code §301.452.

(b) The board shall report to the Texas Department of Public Safety and the Drug Enforcement Administration any of the following:

(1) Any significant changes in the status of the RN license/advanced practice authorization, or

(2) Disciplinary action impacting an advanced practice nurse’s ability to authorize or issue prescription drug orders.

(c) The practice of the advanced practice nurse approved by the board to carry out or sign prescription drug orders is subject to monitoring by the board on a periodic basis.

Repeal and New Chapter adopted effective 11/26/2003